Presentation on theme: "SECTION V CAA SUMMARY June 10, PM"— Presentation transcript:
1 SECTION V CAA SUMMARY June 10, 2015 1-3PM Most Recent Prior AssessmentTypeARDBIMS Summary ScoreMood Interview Severity ScoreCAA Results of Current Assessment
2 ObjectivesUnderstand that the CAA forms a critical link between the MDS and decisions about care planningUnderstand how to write a CAA and what resources are available in the RAI ManualUnderstand what to do with the information put in the CAA
4 V0200: CAA & Care Planning Care Area A.A. Care Area Triggered A.B. Addressed in Care PlanLocation & Date of CAA information (in clinical record)B.1. & 2. Signature of RN Coordinator of CAA Process & Date CAAs CompletedC.1. & 2. Signature of Person Facilitating Care Plan & Date Care Plan Completed
5 Completion Comprehensive Assessment V0200B2. Completion Date of CAAsNo later than 14th day ofEntry/AdmissionDetermination of need for SCSA or SCPAWithin 14 days of ARD of Annual AssessmentV0200C2. Completion Date of Care PlanWithin 7 Days completion of CAAsTransmission of MDSWithin 14 days completion of care plan (V0200C2)
6 CAA PROCESS CARE PLANNING CHAPTER 4CAA PROCESS CARE PLANNINGSeamless circular process begins at admissionand continues until discharge
7 Care Area Assessment - Completion Only Comprehensive OBRA AssessmentsAdmissionAnnualSignificant ChangeSignificant Correction of one of the above assessmentsNot required for Swingbed facilitiesRN CoordinatorEstablish policy for health care professionals to review specific CAAs
8 Care Areas 1. Delirium 2. Cognitive Loss/Dementia 3. Visual Function 4. Communication5. Activity of DailyLiving (ADL) Functional/Rehabilitation Potential6. Urinary Incontinence& Indwelling Catheter7. Psychosocial Well-Being8. Mood State9. Behavioral Symptoms10. Activities11. Falls12. Nutritional Status13. Feeding Tubes14. Dehydration/FluidMaintenance15. Dental Care16. Pressure Ulcer17. PsychotropicMedication Use18. Physical Restraints19. Pain20. Return to CommunityReferral
9 Care Area Trigger(s) Triggers need for further assessment Care Area IndicatorActual ProblemPotential Problem (At Risk)Rehab CandidateNot ProblemTriggered Care Area must be assessedmay or may not warrant being care planningFocus search for root cause of Care AreaMDS may not trigger every relevant issue
10 In-depth Assessment CAA Tools and Resources CMS does not mandate or endorse use of any particular resource(s) including those in Appendix CFacility choice of tool or resourcegrounded in current standards of practiceevidence based or expert endorsed researchclinical practice guidelinesAdequate to guide thorough assessment of Care Area Condition
11 Care Area Assessment Problem 1. Define or Describe the Care Condition orProblemDiagnosisPhysician/Consultant Exams, Diagnostic TestsNursing AssessmentsSigns, SymptomsResident ObservationResident & Staff InterviewWhat exactly is the resident’s problem?
12 Care Area Assessment Cause and Effect Analysis 2. Identify Cause and Effect of the ProblemRoot CauseContributing factorsRisk factorsComplications affecting orcaused by care areaWhat is causing the problem?
13 Care Area Assessment Cause and Effect Analysis 3. Determine effect or impact of theCondition or Problem on the resident’sphysical, functional, psychosocial status.Strengths & abilities to improve.Why is it a problem forthe resident?
14 Care Area Assessment Outcome 4. Decide Care Plan Objective(a) Resolve Care Condition/Problem - Cause, Complication, Risks - when possible(b) Minimize Effect/Impact of Condition/Problem - Cause, Complication, Risks
15 CAA SummaryDESCRIBECause and contributing factor of Care Area ConditionDescription of ConditionWhat exactly is the issue/problem for this resident and Why is it a problem?Objective or Subjective DataPhysical, functional, and psychosocial strengths, problems, needs, deficits, and concerns related to the conditionStrengths and abilities that can improve or maintain current functional statusComplications affecting or caused by care area for resident
16 CAA SummaryDESCRIBERisk factors related to presence of condition that affect decision to care planCauses and contributing factors of resident’s resistance to careNeed for additional evaluation by physician or other health professionalFactors to consider in developing individualized care plan interventions.Name of research, resource(s), or assessment tool(s) used CAA processFor triggered condition that does not warrant care planning: Why determined triggered condition not problem for resident?
17 QIS Question http://www.aging.ks.gov/Manuals/QISManual.htm Accurately and comprehensively reflect resident’s status or condition:Identifies causal factorsRisk or contributing factors for decline or lack of improvementCauses or contributing factors of any resistance to careIdentifies strengths or abilities that can contribute to improvement
18 Appendix C – Care Area Assessment Tool #6. Urinary Incontinence and Indwelling Catheter
19 Chapter 4 Brief Overview of Condition UI is …Types …Aging impact …Is risk factor for complications …Affect ….Catheter Use… problem, risk
20 UI & Catheter Use Triggers Triggering Conditions (any of the following):1. ADL assistance for toileting was needed asindicated by: G0110I1 >= 2 AND G0110I1 <= 4)2. Resident requires an indwelling catheter asindicated by: H0100A = 13. Resident requires an external catheter as indicatedby: H0100B = 14. Resident requires intermittent catheterization asindicated by: H0100D = 15. Urinary incontinence has a value of 1 through 3as indicated by: H0300 >= 1 AND H0300 <= 3
21 Brief Overview of Condition Chapter 4 Cont. Manage Condition:Identify underlying cause(s) of UIReason for indwelling catheterWhy do you need to know?Reduce or eliminate incontinence episodes OR reason for catheter useIf can’t -- manage to prevent complicationsNeed more information – Go back to Section/ Item in Manual read Health-related Quality of Life and Planning for Care
22 CMS Resource Appendix C #16 Urinary Incontinence & Indwelling Catheter Review of UI and Indwelling CathetersSupporting DocumentationModifiable Factors contributing to transitory UIOther factors that contribute to UI or catheter useLaboratory TestsDisease and ConditionsTypes of UIMedicationsUse of Indwelling CathBasis/reason for checking the item, including the location, date, source (if applicable) of that informationNOT JUST CHECK MARKSNOT RESTATING MDSCMS Resource Appendix C #16 Urinary Incontinence & Indwelling Catheter
23 Supporting Documentation Critical Thinking Focus on relationship of checked item to Care AreaSign & Symptom, DescriptionCausal FactorContributing FactorRisk FactorAffect on physical, mental, psychosocial, functional statusStrengthPreference
24 Care Plan Considerations Input from resident and family/representative regarding the care area. (Questions/Comments/Concerns/Preferences/SuggestionsAnalysis of FindingsReview indicators and supporting documentation, and draw conclusion.Document:Description of ProblemCauses and contributing factorsRisk factors related to careCare Plan ConsiderationsDocument reason(s) care plan will/will not be developed.Care plan focus or objectiveNOT Care Plan Interventions or CAA SummaryReferral(s) to another discipline(s) is warranted (to whom and why)
25 Analysis of Findings/CAA Summary Care Planning Identify and Address underlying causes of care area condition, contributing factors develop individualized care planObjective, Goal, and Interventions to promote resident’s highest level of well-being of physical, mental, and psychosocial functioningImprove to extent possibleMaintain current levelPrevent decline to extent possibleIf at risk for decline minimize decline to extent possiblePalliative care – Keep comfortablejde
26 Care Plan Development Comprehensive and Individualized ObjectiveGoal StatementProblemInterventionsBased on Assessment
27 Care Plan Development INDIVIDUALIZE Use information gathered as worked CAA & CAA SummaryCare Area Condition, cause, contributing factors, risk, complicationResident’s needs, behaviors, characteristics, strengths, preferencesInput from resident and familyStandards of practiceReview current care plan to see if condition already addressed and revise if needed based on new assessment
28 Objective and Goal Statement Reasonable Expected Outcome of CareQuantifiable, Measureable with Time FramesImprovement, Prevention, Maintenance, PalliativeObjective and Goal StatementWho is expected to achieve goal? (Resident)SubjectWhat action must take place to achieve goal?VerbUnder what circumstances is the action performed?How well or often must the action be performedModifierTime frameGoalWhat is the time period during which the action must be performed?What is the reasonable expected outcome?
29 Objective and Goal Statement Subjectwill use the bedpanVerbbefore I get out of bed and when I return to bedModifierfor the next 4 weeksTime frameto decrease my incontinent episode to less than 3 per day & to reduce my embarrassment of being incontinent.Goal
30 Select & Implement Interventions Approaches to Achieve Objective/Goal Statement INDIVIDUALIZEInstructions to provide consistent careRelieve or lessencause or symptoms of conditionlimitations to physical, functional, or psychosocial functioningIdentify current treatment and servicesMonitor effectiveness & possible adverse consequencesMedication - Black Box Warnings
31 Select & Implement Interventions Do not need to list all DX – S/S, Notify Dr.Standard of PracticeProtocols when same interventions for several residentsStaff need to know location of protocolsIdentify resident-specific approaches different than protocolAlternative to RefusalsAdvanced care planning and palliative careResources – RAI Manual, Federal Regulation IG, QIS, Standards of PracticeWHO KNOWS THE CARE PLAN?
32 Care Plan Interventions 1. Give me the bedpan:when I wake up in the morning8 ambefore I get out of bed for lunch (11:30)when I go back to bed at 1:30after my afternoon nap (3:00 PM)before I to supper at 5:00 PMafter I go to bed at 7:00 PM12 midnight.2. Elevate the head of bed when you place me on the bed pan.3. If I ask for the bedpan more frequently, take a few minutes to visit with me about my day and tell me how long it has been since I just used the bedpan. If I tell you I still need it, please let me use it.4. When I am wet or had a BM cleanse my bottom with soap and water. Peri wash burns. Use the barrier cream in my top drawer.5. Please offer me water when you come into my room, cappuccino at breakfast, and yogurt for an evening snack.
33 Monitor Progress Evaluate Care Plan Review progress toward goalIdentify if objectives achieved or condition worsened requiring revisionEvaluate response to interventions & treatmentsIdentify factors affecting progress towards achieving goalsDetermine need to stop or modify interventions
34 Questions?I’ll take a few minutes to answer any questions you might have.
35 Thank you!!Please feel free to contact me at any time Shirley L. Boltz, RN RAI/Education Coordinator